HomeMy WebLinkAbout0083 FROST LANE - Health 83-Frost Lane
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LOCATION � fb 0` �dl SEWAGE
VILLAGE a—ti►e S ASSESSOR'S MAP&PARCEL
NAME&PHONE NO. '� `�k Ccs i'� 1 Li - I--)-?
SEPTIC TANK CAPACITY 6Uv
LEACHING FACILITY:(type) (-)tl (size) 24
NO.OF BEDROOMS
OWNER Vo4 v)Gt tk-cA
PERMIT DATE: DATE:3;- f` 0p
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet
Private Water Supply Well and Leaching Facility(if any wells exist
on site or within 200 feet of leaching facility.) feet
Edge of Wetland and Leaching Facility(if any wetlands exist
within 300 feet of leaching facility). feet
FURNISHED BY
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56 Water
32 Service
I—___ —A
Commonwealth of Massachusetts
( Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
IND
83 Frost Lane
r•:
Property Address
Michael Obrien !
Owner Owner's Name 7R:
information is required for every Hyannis MA 02601 4-10-18 ='
.
page. City/Town State Zip Code Date of Inspection '
Inspection results must be submitted on this form. Inspection forms may not be altered-in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out
outout forms `���gtltltltrpf�
use only he tab \`�` �,jNon the computer,
key to move your 1. Inspector:
cursor-do not $ G
use the return James D.Sears _ JAMES •.m
key. Name of Inspector `C-,; SEARS ;
Capewide Enterprises
"ICI Company Name �T
153 Commercial Street ''%;F s IN S?:'`
Company Address
Mashpee MA 02649
City/Town State Zip Code
508-477-8877 S 1623
Telephone.Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
4-12-18
nspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection, If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
6/18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
�� VS
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
I> Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
C
83 Frost Lane
Property Address
Michael Obrien
Owner Owner's Name
information is
required for every Hyannis MA 02601 4-10-18
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
T he system is a 1000 Gal. Tank D Box and eight chamber's Note: Outlet tee has a zable filter.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑'Y ❑ N ❑ ND (Explain below):
t5km.doc rey'6Y6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Frost Lane
Property Address
Michael Obrien
Owner Owner's Name
information is required for every Hyannis MA 02601 4-10-18
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
83 Frost Lane
Property Address
Michael Obrien
Owner Owner's Name
information is required for every Hyannis MA 02601 4-10-18
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that-no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in is less than 6" below invert or available volume is less
than '/day flow ,��/)egljv;
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
r--
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
F' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
83 Frost Lane
V
Property Address
Michael Obrien
Owner Owner's Name
information is Hyannis MA 02601 4-10-18
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
9 p Y rY
83 Frost Lane
�u
Property Address
Michael Obrien
Owner Owner's Name
information is Hyannis MA 02601 4-10-18
required for every
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 2 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�o
!% 83 Frost Lane
Property Address
Michael Obrien
Owner Owner's Name
information is H required for every annis MA 02601 4-10-18
Y
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
1000 Gal. Tank D Box and eight chamber's.
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ® Yes ❑ No
Water meter readings, if available last 2 ears usage d na
9 ( Y 9 (gp ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NA
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
'le Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�V
83 Frost Lane
Property Address
Michael Obrien
Owner Owner's Name
information is required for every Hyannis MA 02601 4-10-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
AM, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Frost Lane
Property Address
Michael Obrien
Owner Owner's Name
information is required for every Hyannis MA 02601 4-10-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
2008 permit 2008 -454 New Leaching.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 44"
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH -40.
Septic Tank (locate on site plan):
Depth below grade: 34"
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 Gal. Precast H-10
Sludge depth:
1"
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Frost Lane
�V
Property Address
Michael Obrien
Owner Owner's Name
information is required for every Hyannis MA 02601 4-10-18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness
0"
8
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
18"
How were dimensions determined? Asbuilt-Plan-Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level. Tank at 34" below grade w/both covers at 6". In and outlet tee's. No sign of
leakage or over loading. Note: Tank outlet tee has a zable filter.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Frost Lane
v-
Property Address
Michael Obrien
Owner Owner's Name
information is required for every Hyannis MA 02601 4-10-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
83 Frost Lane
Property Address
Michael Obrien
Owner Owner's Name
information is Hyannis MA 02601 4-10-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x16"-4' below grade w/cover at 2'. Box is clean and solid w/two lines out. No sign of
over loading or solid carry over.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site,plan, excavation not required):
If SAS not located, explain why:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
emu-
83 Frost Lane
Property Address
Michael Obrien
Owner Owner's Name
information is required for every Hyannis MA 02601 4-10-18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 8
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is eight Biodiffuser chambers. Two row's of four each. Camera out and ck inspection port.
Clean and dry w/no sign of over loading or solid carry over. no sign of holding water.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
I
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
`Ic Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Frost Lane
Property Address
Michael Obrien
Owner Owner's Name
information is required for every Hyannis MA 02601 4-10-18
page. City[Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
ie Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.� 83 Frost Lane
u
Property Address
Michael Obrien
Owner Owner's Name
information is required for every Hyannis MA 02601 4-10-18
page. Cityr'rown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
A_3
t5ins.doc•rev.6/16 Title 5 Official Inspection.Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
(! Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Frost Lane
V�
Property Address
Michael Obrien
Owner Owner's Name
information is required for every Hyannis MA 02601 4-10-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells O
dV
Estimated depth to high ground water:
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: 10-20-08
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
T.H. on Design plan 10-20-08 11' no G.W.. Bottom of chamber's at 4'-T below grade. Bottom of
chamber's at 6'-6"above T.H. Depth.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Fe Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Frost Lane
,•V
Property Address
Michael Obrien
Owner Owner's Name
information is required for every Hyannis MA 02601 4-10-18
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
83 Frost Lane __—___—_-------
Property Address
Eric Vohnoutka
Owner Owner's Name
information is Hyannis MA 02601 September 11, 2008
required for State Zip Code Date of Inspection
every page. City/Town
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important: A. General Information S ��
When filling out
forms on the
computer,use 1, Inspector:
only the tab key
to move your Patrick M. O'Connell
cursor-do not Name of Inspector
use the return
key. Septic Inspection Services Co _ ____.____—_._____._—_
Company Name
ee 189 Cammett Road
Company Address 02648
Marstons Mills MA
iemm City/Town State Zip Code
508-428-1779 _--__ Sl12855
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
❑ Passes ❑ Conditionally Passes ® Fails
❑ Needs Further Evaluation by the Local roving Authority
=- September 11, 2008 —
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
1 itle 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 1 of 15
08-236 Vohnoutka.doc•08106
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Frost Lane
Property Address
Eric Vohnoutka
Owner Owner's Name
information is Hyannis MA_ 0260_1_ September 11, 2008
required for -- --- - State Zip Code Date of Inspection
every page. City/Town
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/ always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
08-236 Vohnoutka.doc 08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 2 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Frost Lane
Property Address
Eric Vohnoutka
Owner Owner's Name
information is Hyannis MA 02601 September 11, 2008
required for ----
State Zip Code Date of Inspection
every page. Cityfrown
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑. Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
08-236 Vohnoulka.doc•08/06 Tale 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Frost Lane
Property Address
Eric Vohnoutka
Owner Owner's Name
information is Hyannis MA 02601 September 11, 2008
required for - ----- --
every page. CityrFown State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This asses system if the well water analysis, performed at a DEP certified laboratory, for coliform
Y P y
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other.
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes No
® ❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than_day flow
El ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
08-236 Vohnoutka.doc•08/06 Title 5 Offiaai Inspection Form.Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Frost Lane
Property Address
Eric Vohnoutka
Owner Owner's Name
information is Hyannis MA 02601 September 11, 2008
required for
every page. City/-rown State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
08-236 Vohnoutka.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Frost Lane
Property Address
Eric Vohnoutka
Owner Owner's Name — — ----------------- ------------- —
information is Hyannis MA 02601 September 11, 2008
required for y ---- ----- -- ---
every page. CityTTown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
21 ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ Existing information. For example, a plan at the Board of Health. .:
El approximation
in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)] -
08-236 Vohnoulka.doc•08106 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Frost Lane
Property Address
Eric Vohnoutka
Owner Owner's Name
information is required for Hyannis MA 02601 September 11, 2008
-
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 2- Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example. 110 gpd x#of bedrooms): 220
0
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): --
Sump pump? ❑ Yes ® No
Vacant 3 months
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment: - ---- -----
Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.): -- — ------ - -----
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank.present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: - - - - -------
Last date of occupancy/use: Date_. _--
Other(describe): -— -- -------- ---
08-236 Vohnoutka.doc•08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Frost Lane
Property Address ---- ------------ ---- --
Eric Vohnoutka
Owner Owner's Name
information is required for Hyan
nis MA 02601 September 11, 2008
- -
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: None
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: -- --- ------------- -
gallons
How was quantity pumped determined?
Reason for pumping: - -
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
Approximate age of all components, date installed (if known) and source of information:
Compliance date: 5/15/87 ------------ ------------------------ —
Were sewage odors detected when arriving at the site? ❑ Yes ® No
08-236 Vohnoutka.doc•08/06 ride 5 Official Inspection Form Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Frost Lane _
Property Address
Eric Vohnoutka
Owner Owner's Name
information is Hyannis
MA 02601 September 11, 2008
required for H-- --
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
3'
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain): ----
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
3' _
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
-----------------------------------------------------------------------------------------------------------------------
8.5' long x 5.2'wide- 1000 gal.
Dimensions:
8"
Sludge depth:
22"
Distance from top of sludge to bottom of outlet tee or baffle - -- --
6"
Scum thickness --
6"
Distance from top of scum to top of outlet tee or baffle ------- -- —-----
8"
-
Distance from bottom of scum to bottom of outlet tee or baffle
Measured
How were dimensions determined?
08-236 Vohnoutka.doc•08106 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form Not for Voluntary Assessments
83 Frost Lane
Property Address
Eric Vohnoutka
Owner Owner's Name
information is required for Hyannis MA__ p
02601 September 11, 2008
—� _--.._.... —
every page. CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Baffles intact and liquid level was found at bottom of outlet invert.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle ----
Distance from bottom of scum to bottom of outlet tee or baffle -- ---- --
Date of last pumping. Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: --
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
08-236 Vohnoutka.doc•08/06 1ule 5 Official Inspection Form Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Frost Lane
Property Address
Eric Vohnoutka
Owner Owner's Name
information is required for Hyannis MA 02601 September 11, 2008
-
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: ---- — Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
011
Depth of liquid level above outlet invert ------------ ---
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
08-236 Vohnoulka.doc•08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 11 of 15
I
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Frost Lane
Property Address
Eric Vohnoutka
Owner Owner's Name
information is Hyannis MA 02601 September 11, 2008
required for -- --
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑C leaching pits number: One 600 gal. pit
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length: ---
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology: -_--..--
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
.Leaching pit was found empty with a high stain line at top of pit, pit is in hydraulic failure.
08-236 Vohnoutka.doc•08106 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 12 of 15
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
83 Frost Lane _
Property Address
Eric Vohnoutka
Owner Owner's Name
information is Hyannis _MA 02601 September 11, 2008
required for Y p
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration —
Depth-top of liquid to inlet invert
Depth of solids layer --
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction: -- -- - -- ---- —
Dimensions ---
Depth of solids -- ------ ------ ---- —
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
-- ---- - --- --------- -- - .... _----___... - ...-........----------- - -------
08-236 Vohnoulka.cloc-08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i. Subsurface Sewage Disposal System Form Not for VOluntary Assessments
83 Frost Lane
-
----- --_ ...._.. _.
Property Address
Eric Vohnoutka
Owner Owner's Name
information is H annis MA 02601 September 11. 2008
required for -- -p- - _._..----------
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide.a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
`8"
1 26
2
28 Water
56 32
Service
r�
Frost Lane
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Frost Lane _
Property Address
Eric Vohnoutka
Owner Owner's Name
information is P required for �s H anni MA 02601 September 11, 2008
_ _
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to ground water: N/Afeet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database -explain.
You must describe how you established the high ground water elevation:
08-236 Vohnoutka.doc•08106 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 15 of 15
CC'T.24.2008 8:33AN ATTY KRA KENNEY N0.548 P.1
Bk , 23228 F':w272 0546381
Y9E>gY�lE5'1'RiG° d®1+1
WEMAS,IERIC VOHNOrTAKA,of 93 Union Street,Wespart,
Massxhusetts,is the owner of land and buildings thereon located at 83 Etost Lanz ,
HyMnis,]ka table Countv, -husetts,and being shown as Lot. 11 on a plan entitled
"Resubdivision of,Lots 4-6&g,in Hyannis,Mass.Property of Miles&Elizabeth Frost
Sydney Scale, 1 in.=50&—July 29,1961 Ed Kellog--Civil Eng'r.Osterville',which
said plan is duly recorded with Barnstable County Registry of Deeds in Plan Boob 164,
Page 5%
WHMIEAS,ERIC'V'OHNOUT",A,as the owner of said lot has agreed Nvith
the Town of Barnstable Board of Health to a.restriction as to the number of bedrooms
Which can be included in any home built on said lot as a pre-condition to obtaining a
disposal works construction pezrxzit in compliance writh.310 CMR 15.000 State
Environmental Code,Title V,Minimurta Requirements for the Subsurface Disposal of
Sanitary Sewage;
VMEREAS,The Town of B amstable Board of Health,as a pre-condition to
granting a disposal works contraction permit for a septic system in compliance with 310
CMR.15.200,State Environmental.Code,Title V.Minimum Requhtments for the
Subsurface Disposal of Sanitary Sewage,and authorizing the issuance of a building
permit for the construction of a single family horse on this property,is requiring that the
agreement for the restriction on the cumber of bedrooms in any house constructed on the
lot be put on record with the Bamtable County Registry of feeds by recording this
document.
NOW,THEREFORE,ERIC'VOUNOUTTAKA, does hereby place the following
restriction on his above-referenced land in accordance with his agreement with the Town
of Barnstable Board of Health,which restriction shall rm with the land and be binding
upon successors in title,
1. 83 Frost Lane.Hyaatn1 Barnstable County,Massachusetts.may have
o =a TOVml
constructed upon the lot a house containing no more than. TWO(2)bedrooms.
EUC V013NOU'TAKA agrees that this shall be a petta=errt deed restriction or
until such time Barnstable Board of Health ohanges their regulations or town
sewer becomes available affecting Lot 11,located in Hyannis,Barnstable County,
Massachusetts,and being shown on the plan recorded in Plan Book 164,Page 57.
For tide of E1.2$C VONNOUTAIgA,see the following deed:Book 19984,Page
239.
CK--T.24.200e 8:3 4AM ATTY JOHN KEHHEY 23ZVO.548q 2P.2 #54688
Bk
F—xecuted as a sealed imst nvnent tis day of October, 2009.
ERIC V'OMOU aA.KA
C ACWI1S'T'T TS
Bamstable,s&
on this day of October,2008,before me,the undersigned notary public,
personally appeared ERIC VORNOUTAKA,proved to me through satisfactory
evidence of identification, _,to be the person whose
name is sued on the preceding or attached document,axed acknowledged to me that he
signed it voluntarily for its sited purpose.
Nary biid:
'ssion expms:
i
UNSTABLE REGIST"Of DEEDS
TOWN OF BARNSTABLE
LOC?,TION �.3 %n S� C),1 SEWAGE# '2ao6- i;4
- VILLAGE ASSESSOR'S MAP&PARCEL /2
INSTALLERS NAME&PHONE NO. �,��0 �� . - YZ
SEPTIC TANK CAPACITY /60 0 f-1/G
LEACHING FACILITY:(type) V', &C, "7,-,0(size)
NO.OF BEDROOMS
OWNER Er 'C V y d C\ Nco,
PERMIT DATE: 10-14 - 2,00% COMPLIANCE DATE: 1 0 ZOOS
Separation Distance Between the:
0
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility // Feet
Private Water Supply Well and Leaching Facility.(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY � t1lk9 t� &Lt qpn�e-3 L,(,L
AZ
2tv,�
31f. u
r3 I
S 6a 3v • 0
3 YC. v •
5-, S
J
No. [✓ PeeL(
THE COMMO NEALOF MASSACHUSETTS_' Entered in computer:
PUBLIC HEALTH DIVISION - TOWN IOF BARNSTABLE, MASSACHUSETTS Yes
0ppgicatiou for TDi5po5al *p5tem (Con0truction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No. � S� ��gL Owner's Name,Address,and Tel.No. C_
Assessor's Map/Parcel oc p
Installer's Name,Address,and Tel.No.CQ e.,+&C t f\lzC'ec-; Designer's Name,Address and Tel.No.
yz6, q o2' Po. 3 c,Y.-, SDIS
Type of Building:
Dwelling No.of Bedrooms Lot Size uCIL,.%t sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) * gpd Design flow provided gpd
Plan Date Its• E V Zoo'b Number of sheets Revision Date
Title ?.)i) �k- roSk 1"4 ,": S
Size of Septic Tank `(�o I" Type of S.A.S. _� l\cZ.G 3Co�C_ ��cs���r i►Sec�
Description of Soil se P ��� � C '
Nature of Repairs or Alterations(Answer when applicable) _e X7,-5 Jn C1Q.l�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Boar Health.
Signed Date
Application Approved by � 'G�✓`� Date
Application Disapproved by: Date
for the following reasons
Permit No. (900 � Date Issued
No. �./ F.�
v ;d�ry,r���Z, � �;+ Fee �
A Entered in computer: --�
� THE COMMONWEALTH OF MASS CHUS �TSB'' p Yes
PUBLIC HEALTH,DIVI-SIlu .. - TOWN OF -BARNSTABLE,:ASSACHUSETTS
gicatiou for D14w6a.�*� f*.5tem Cowaruction Permit
Application for aTermit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑.Complete System ❑Individual Components
°- Location Address or Lot No. `J� f� Owner's Name,Address,and Tel.No.
N
t._ y(L"X-kk Cis o� �
Assessor's Map/Parcel
lnstaller's Name,Address,and Tel.No. , Designer's Name,Address and Tel.No.
'S L Z'5• u o2.56 Pc7 P ,`��0
G ► .��,
Type of Building:
Dwelling No.of Bedrooms Cot,Size e-i `,qj sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) - 7 Z c--> gpd' Design flow provided 2_j� , gpd
Plan Date 1 n. 7 Number of sheets {t Revision Date
Title �2 c nS�t4 !,
Size of'Se tic Tank J
P � l Type of S.A.S. QA o 2r 11 r ?., .►. C\. .���e�
Description of Soil
,
Nature of Repairs or Alterations(Answer when applicable)
f
.t
Date last inspected:
t
Agreement: r
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
has
Compliance
p s been issued by this Board of Health.
Signed _ Date
Application Approved by ��m \� r^^ Date //a / �I��k"
Application Disapproved by: Date
for the following reasons
Permit No. i--9 cc)R Date issued /0 14Z4 69
THE COMMONWEALTH OF MASSACHUSETTS
o � BARNSTABLE, MASSACHUSETTS
to Certificate of Compliance
THIS IS TO CER,TTIIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( �) Upgraded ( )
Abandoned( )by e. ,�, V.A � A
at 1�� se n � �. . _ ��� has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. ` dated
Installer Designer
#bedrooms r \� Approved design flow, ,( n� "� gpd
The issuance oaf this permit shall not be construed as a guarantee that the system willlfunction as�designecl.
f
Date ��/�'/ �� Inspector l� �V:
� "w vv V F
it ------ ---------� _
No. l s� Fee lti 0 ---- --------
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS a
�hgpoar �§p!tem Con5truction Permit
Permission is hereby granted to Construct ( ) Repair ( -Kj Upgrade ( ) Abandon ( )
System located aty Q� C,r s r.� 1 �.,.�. Q\
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date ofof t�rmit"
°": ( 1
Date / � � Approved b�y
I
Town of Barnstable
P#
T�
Departiment of Regulatory Services
Public Health Division Date D
200 PIain Street,Hyannis MA 02601
QED AAOtt�
3®
Date Scheduled OffTim Fee Pd.
—J00
Soil Suitability Assessment for Sewaple Disposal a
Performed By:_M'tw4 ��niENfb-, �,�.T, Witnessed By:
9
LOCATIONMENERAL INFORMATION
Location Address 3 Y30/1's
Owner's Name C h pr�is 13
Address
Assessor's Map/Parcel: 2 ci p 1 t Engineer's Name egry ;t l.� t e-ef I''<)
NEW CONSTRUCTION REPAIR Telephone# ) Q Y)-8 �L(°2 ij
Land Use �>cs�CENnilt f YA(10 P&16 Slopes(9'0) 0'3`rc Surface Stones 1144
Distances from: Open Water Body :,15o ft Possible Wet Area >150 ft Drinking Water Well 915o ft
Drainage Way -moo ft Property Line 710 ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
�TPt
�17L
MAP VA
Y 3f..Qtn`
xflt&: rl.Ts.
Parent material(geologic) 0,rWAS11 Depth to Bedrock
Depth to Groundwater. Standing Water in Hole: IyZ, �S Weeping from Pit Face >1yZ 3rr'•S
Estimated Seasonal High Groundwater i,l�L" i3(oS
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used: "t �R>F�.>• OI&sE99Aftoty
Depth Observed standing in obs.hole: �19t'$45 ia. Depth to soil mottles., 91'IZ� BfOS in.
Depth to weeping from side of obs.hole: >KIL" in. Groundwater AdJustment Nl� ft.
..
Index Well# Reading Date: " Index Well level Ad{,}Actor Adj.Groundwater Level
PERCOLATION TEST bate !!I av Time ►l-yo4m
Observation
Hole# Time at 4"
M
Depth of Perc S4-St," Time at 6"
' Start Pre-soak Time @ tl:ND -_ 'lime(9"-6")
End Pre-soak 1i.:51
Rate Min.'/Inch < 2 MP%
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)_ /
Original: Public Health Division Observation Hole Data To Be Completed on Back-----------
***If percolation test is to be conducted within 100' of wetland,you must first notify the.
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:\SEPTICIPERCFORM.DOC
DEEP.OBSERVATION HOLE LOG Hole# 0
Depth from Soil Horizon Soil Texture .Soil Color Soil, Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.% ravel
al"_(93 A I..AMV SANA 10 ,L ;II
to.._ „ g t-o,tmy 3Anlo to YQ.5�10 —
3+•1•
H2 C M60,-C'o1%9s61A 254
i
DEEP OBSERVATION HOLE LOG Hole# 2-
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
o-y" -- '• — �' Few
y',10•° A 60AMf 5An10 00 vt 4It
WAffif SAW to Y- 56. - -
3y'-:i�tti' N►eo: Rse 5ANo 2.5y (0Ie — LC OSF-
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
C n i to c Gravel)
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones',Boulders.
Consistency,%LQMxtI
Flood Insurance Rate Map:
Above 500 year flood boundary No_ Yes _
Within 500 year boundary No r�/ Yes
Within 100 year flood boundary No Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring pervious material?
Certification _
I certify that on /° 17- (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with .
the required training,expe 'se and xpenence described in 310 CMR 15.017.
Signature Date
Q:\.S.EPTICIPERCFORM.DOC
Qw� 01 uAri 1SCame
I
regulatory Servlccs ' I #
it a i ;Tliom" F. Geller,Di�rectdr'
Public Health DiViaion ti
:! � Thomas an, Director'
Is � I
Street A minis I I '
I 2001VIain Y ,IIVIA QZ601!
I {
Office: 508-962�-464
i i I Fax 50�3�790.63'04 i
i� Installer & Desigµer�,C�rtif{ction Form
�5
I}esj iel. Gw Ei'1 a� eci ✓+�(. .
. Installer: ; ' � ew F —f1 r`5�.
, I s
Atldre,ss: � ? . .:Cn�rr�r AdtlreBs: i` ® �,�/ Z(o
OTI _ " was issued a permit to install �l k
(d�ite) I (insta}ler)
Septic system[at o_��t based on`;a
-- design drawn by
(address)
�ated} OCA4a
1(d.esigner)
I I ,
i` y - j � , r j• i I i � i
I c edify that the septic system referenced abU�ef'was iristialled!substanitial] accord'
the cleat y ink to i
i= gn, which ray inelud rjnmQx approved changes such ins Iraterai relocation of the
;+ distrikkutioh box and/or septic tank. ( i
j
I
I,certify that ;th,e septic sy,stern referenced abcsve was initalled with major changes (i"e.
greater than 10' lateral relpcakon of the SAS or any vertcat relocation of any component ,
i of the�septzc: system!) but iz accordance with State BuI,ocal Re 'ultiolisi Plan revision car
certified as-built by'design!er to f'ollovy, i ` i j 'i 1 ' iOp
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is ( stall, s
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!� Q: Health/sept►c/Designer Certikfttian Fbrm
iC t=i '•� j L9210; i.LZ 809 I `>N I a33N I JN33I Wd V0: 20 800Z_LZ_130 j<
ECOJECH
Environmental �o
www.eco-tech.us ypo '9
�9( 9 THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MA S ,LSETyf)E PART ENT
OF ENVIRONMENTAL PROTECTION(revised 6/15/2000) >1
TITLE 5
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESS TS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 83 Frost Lane
Hyannis
Owner's Name: Stephen Milo
Owner's Address: 272 Yorkshire Ct
Naples,FL 34112
Date of Inspection: July 8, 2002 PARCEL . , 21
Z..
Name of Inspector:(Please Print) David D. Coughanowr,R.S. LOT i
Company Name: Eco-Tech Environmental
Mailing Address: 43 Triangle Circle
Sandwich,MA 02563
Telephone Number: (508)364-0894
CERTIFICATION STATEMENT:
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on-site sewage disposal systems. I am a DEP
approved system inspector pursuant to section 15.340 of Title 5(310 CMR 15.000).The system:
X Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature 1J.,-( Date: T �Ay 10, WO-2-
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority
NOTES AND COMMENTS
Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger
any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed
on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination.
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 83 Frost Lane
Hyannis
Owner: Stephen Milo
Date of Inspection: July 8, 2002
INSPECTION SUMMARY: Check A,B,C,D or E/ALWAYS complete all of section D:
A] System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR
5.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] System Conditionally Passes:
One or more system components as described in the "Conditional Pass" section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no, or not determined(Y,N,or ND). in the_for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not),is structurally
unsound,exhibits substantial infiltration or exfiltration, or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or breakout or high static water level in the distribution box is due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if(with
approval of Board of Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced.
ND explain
The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain
2
I -
Page 3 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 83 Frost Lane
Hyannis
Owner: Stephen Milo
Date of Inspection: July 8, 2002
C) Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
s failing to protect public health, safety and environment.
1 System will pass unless Board of Health determines in accordance with 310 CMR 15.303 (1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2) System will fail unless the Board of Health (and public water supplier,if any) determines that the
system is functioning in a manner that protects the public health,safety,and environment
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed by a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form
3) OTHER
3
t _ Page 4 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 83 Frost Lane
Hyannis
Owner: Stephen Milo
Date of Inspection: July 8, 2002
D)System Failure Criteria applicable to all systems:
You must indicate either"yes" or"no"to each of the following for all inspections:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.
The basis for this determination is identified below. The Board of Health should be contacted to determine what
will be necessary to correct the failure.
yes no
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
X Any portion of the SAS, cesspool or privy is below high groundwater elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well
X Any portion of a cesspool or privy is within 50 feet of a private water supply well
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis.(This system passes if the well water analysis,
performed by a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form)
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore, the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E)Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd
You must indicate either"yes" or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well.
If you have answered"yes" to any question in Section E the system is considered a significant threat,or answered
"yes" in section D above the large system has failed.The owner or operator of any large system considered a
significant threat under section E or failed under section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 83 Frost Lane
Hyannis
Owner: Stephen Milo
Date of Inspection: July 8, 2002
Check if the following have been done: You must indicate either"Yes" or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant or Board of Health.
X Were any of the system components pumped out in the last two weeks?
X Has the system received normal flows in the previous two week person?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system obtained and examined?(if they were not available as N/A)
X Was the facility or dwelling inspected for signs of sewage back-up?
X _ Was the site inspected for signs of breakout?
X Were all system components,excluding the SAS. located on site?
X Were the septic tank manholes uncovered, opened,and the interior of the septic tank inspected for
the condition of the baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge and depth of
scum.?
X _ Was he facility owner(and occupants,if different from owner) provided with information on the proper
maintenance of subsurface disposal systems?
For information on the proper maintenance of subsurface disposal systems please go to:
WWW.ECO-TECH.US
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
X _ Existing information. For example,Plan at the Board of Health.
X Determined in the field(if any of the failure criteria related to part C is at issue,approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 83 Frost Lane
Hyannis
Owner: Stephen Milo
Date of Inspection: July 8, 2002
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 392 gpd
Number of current residents 2
Does the residence have a garbage grinder(yes or no): no
Is laundry on a separate sewage system(yes or no): no :(If yes, separate inspection required)
Laundry system inspected (yes or no): n/a
Seasonal use(yes or no): no
Water meter readings, if available(last two year's usage(gpd): %j V4
Sump Pump(yes or no): no
Last date of occupancy: current
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow(based on 310 CMR 15.203):: gpd
Basis of design flow(seats/persons/sgft/etc.):
Grease trap present: (yes or no)
Industrial waste holding tank present: (yes or no):
Non-sanitary waste discharged to the Title 5 system: (yes or no).
Water meter readings, if available:
Last date of occupancy/use:_
OTHER: (Describe):
GENERAL INFORMATION
PUMPING RECORDS
source of information: System not pumped in recent past(Owner)
Was system pumped as part of the inspection: (yes or no) No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM:
X Septic tank,distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes, attach previous inspection records,if any)
Innovative/Alternate technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe)
APPROXIMATE AGE of all components,date installed(if known)and source of information:
Age: 15+years Certificate of Compliance issued 5/15/87 (BOH permit#86-1131)
Were sewage odors detected when arriving at the site: (yes or no) no
6
Page 7 of I
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION continued
Property Address: 83 Frost Lane
Hyannis
Owner: Stephen Milo
Date of Inspection: July 8, 2002
BUILDING SEWER_(Locate on site plan)
Depth below grade: 3 ft
Material of construction: cast iron X 40 PVC_other(explain)
Distance from private water supply well or suction line 20+
Comments: (on condition of joints,venting,evidence of leakage, etc.)
Sewer is vented through roof and appears structurally sound with no evidence of leakage or backup into dwelling_
SEPTIC TANK: X (locate on site plan)
Depth below grade: 30"
Material of construction: X concrete -metal_fiberglass—polyethylene
other(explain)
If tank is metal,list age Is age confirmed by Certificate of Compliance (yes or no):_(attach a copy of
certificate)
Dimensions: 8.5 ft x 5 ft x 5 ft(1000 gallon)
Sludge depth: 8 in
Distance from top of sludge to bottom of outlet tee or baffle: 26 in
Scum thickness: 6 in
Distance from top of scum to top of outlet tee or baffle: 7 in
Distance from bottom of scum to bottom of outlet tee or baffle: 11 in
How dimensions were determined: Probe to top of tank
Comments: (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
Pumping recommended at this time. Liquid level at outlet invert. Tank and tees appear structurally
sound and functioning as intended. No evidence of leakage in or out.
GREASE TRAP: none (locate on site plan)
Depth below grade:
Material of construction:_concrete metal_fiberglass_polyethylene
other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:_
Date of last pumping:
Comments: (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 83 Frost Lane
Hyannis
Owner: Stephen Milo
Date of Inspection: July 8, 2002
TIGHT OR HOLDING TANK: none (Tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal _fiberglass_polyethylene_other(explain)
Dimensions.-
Capacity: gallons
Design flow: _gallons/day
Alarm present(yes or no):
Alarm level: _ Alarm in working order(yes or no):_
pumping:Date of last
Comments:(condition of inlet tee,condition of alarm and float switches, etc.)
DISTRIBUTION BOX: X (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: at outlet invert
Comments:(note if box is level and distribution to outlets is equal,any evidence of solids carryover,any evidence of
leakage into or out of box, etc.)
D-box appears structurally sound with no evidence of leakage in or out Effluent level at outlet invert
Few solids in tank.
PUMP CHAMBER: none (locate on site plan)
Pumps in working order: (yes or no)
fl Alarms in working order: (yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 83 Frost Lane
Hyannis
Owner: Stephen Milo
Date of Inspection: July 8, 2002
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan;excavation not required)
If SAS not located, explain why:
Type:
X leaching pits,number 1
_leaching chambers,number
_leaching galleries,number
_leaching trenches,number, length
_leaching fields,number,dimensions
_overflow cesspool,number
—innovative/alternate system Type/name of Technology
Comments: (note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.)
Soils above leach pit appeared unsaturated.No evidence of surface yonding breakout lush vegetation,or
other evidence of hydraulic failure was observed. Leach pit contained 28 inches of effluent.
CESSPOOLS: none (cesspool must be pumped at time of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,
etc.):
PRIVY: none (locate on site plan)
Materials of construction:
Dimensions:_
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 83 Frost Lane
Hyannis
Owner: Stephen Milo
Date of Inspection: July 8, 2002
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100'(Locate where public water supply enters the building)
LOCATIONS
A B
1 21 ft 26 ft
2 29 ft 32 Ft
3 28 ft 56 ft
3 BEDROOM
DWELLING
# 83
A B
w
I z
SEPTIC o J
TANK
w
LEACH <
PIT O 30
D-BOX
FROST LANE NOT TO SCALE
10
f
Page 11 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 83 Frost Lane
Hyannis
Owner: Stephen Milo
Date of Inspection: July 8, 2002
SITE EXAM
Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to ground water: 12+ feet
Please indicate(check)all methods used to determine high ground water elevation:
X Obtained from system design plans on record-If checked. date of design plan reviewed 10/27/87
Observed Site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of health-explain:
_ Checked local excavators, installers-attach documentation)
X Accessed USGS database
You must describe how you established the high ground water elevation.
Approved design plan on file with Board of Health showed bottom of pit to be 5.8 ft above the bottom of
witnessed test pit in which no groundwater was observed. At the time,9/22/87,the groundwater
adiustment would have been 4.5 feet. (Index well MIW-129 Zone C,level= 9.1). This leaves the bottom
of the pit more than 1.3 feet above adjusted high groundwater
11
v , 443
' aa TOWN OF B.ARNSTABLE
443
LOCATION Lo + It ' I-- ,vf SEWAGE # 31
VILLAGE dr/J t S ®l
ASSESSOR'S MAP 6z LOT
INSTALLER'S NAME & PHONE NO.� �0 2 i,N1 3E. 0- 3 B�B
SEPTIC TANK CAPACITY 100o. .
LEACHING FA [,,®C7 �r' t (sue)
NO. OF BEDROOMS A PRIVATE WELL OR PUBLIC WATER , C
BUILDER OR OWNER G2 t es C1
DATE PERMIT ISSUED: i o -2-7
DATE .COMPLIANCE ISSUED: v ^ 15 -7
VARIANCE GRANTED: Yes No
4
Upper Cape Engineering
P.O. BOX 616, EAST SANDWICH, MASSACHUSETTS 02537 (617)362-6281
Sept 23, 1987
Barnstable Board of Health
397 Main Street
Hyannis, Mass,
RE:- Lot Frost Lane
(' r% lS �f.
Dear Sir:
We have caused to inspect the septic system at
lot 10 Frost Lane, Hyannis and Have found it to con-form to
the plans submitted by A-11 �Qape Enginnering.
hn Jacobi
ASSESSORS MAP NO: 292
PARCEL NO.: f o - `-sue
No. .4... �.. Fins....
THE COMMONWEALTH OF MASSACHUSETT4�17�f
BOARD OF HEALTH �1 w/ ---------------OF..... ... . ..........._....� SUPERVISE
T B 'v� STALLEDLA0N AND CERTIF t v ITiNG ,
lltrF$ i11�Y1L1X �tStII� lxk� � Bi $x1Cilt IN sTRfC
�yO PLAN.
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
'� ✓l l
....._.... _. a.......... ...-•••----•-•--•--....-- �-- ------•------------------------------------ �� ------.....----------....................
ocation Addre � or Lot No.
--._.....-� T� -. ......----••......•-----•---- ---•...................••---•------•------...........--••-....._....----
�nsta
Address
�__..... :............ :....Address
.01
4 Type of Building Size Lot__ /_ ---Sq. feet
Dwelling—No. of Bedrooms...---a.................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building No. of persons............................ Showers
� YP g -•--•---•----------•-------• P ( ) — Cafeteria ( )
dOther fixtures -------------------------------•----------------•-----...-------------------------------------------------•----------•------------•---....._......_....
W Design Flow.............................. 0�___gallons per person day. Total daily flow---- �.............._.......•..gallons.
1:4 Septic Tank—Liquid capacity/,.4®__gallons Length... Width-_-C.e... Diameter.__...—__.__ Depths`&,
isposal Trench
' '.................. Width.................... Total Length..........-......... Total leaching area.....................sq. ft.
Seepage Pit No._ .... ------ Diameter---/®........... Depth below inlet_. .5.•`.... Total leaching area..Z®-+...sq. ft.
Z Other Distribution box Dosing tank ( )
Percolation Test Results Performed by.... L.� � _�, '!� t.`e� .._._ Date.- '-..Z_Z-.9,4........
aTest Pit No. 149A __" minutes per inch Depth of Test Pit----- Z....... Depth to ground water......_--.............
L=, Test Pit No. 2......."......minutes per inch Depth of Test Pit...... _ `.... Depth to ground water--------..—..._.-------
(x ......•----•----------------•--•-...••--....-••--•--•-•----••--•-•••------..........._....---•---•-•.........................................
-------------
0 Description of Soil--••••./-•-•••�"®p-----------` -----��i�>J>v� ip '
U --••---•••-•--•-•--••-••--••••--•--•-••-••--•••-•-•••---•-•-•----••---•••-----•--•-•-•----•...••--•...••••----•---••---.....---••---•••-••-•--------
------------------------------------------------ --------•---------------------••-•----•------...-•-------------•----.......-----...--••-----•--•---.....••--••--•--••-••-•............-•-••-•-----.....
V Nature of Repairs or Alterations—Answer when applicable._..............................................................................................
------------------------------------•-----------------------------------•--------•••....._..._------------....•-•--•---••-•••-•--•-•-------•-•-•-•••••••-----•-•-••••••••-•••-••••.....................
Agreement: '
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TTT ." 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been jssued by the board of he�,Ie,
h.
�, 7�i"ol_e_ S s j 1-V
Signed----------- -- ..-• -----• --- --- •--• ------------- ./�O-•D
Application Approved BY ------------•--- ....•. --•-- =
Date
Application Disapproved for the following r ons:---•-••••••-•-••-••---•-•-••-----••-----•--•-•-••---•-•--•---••••---------••••---•---•-•--.. ------••.. -
---•--•-------•-••--••••••••--••....--•-•..._._....•-----------•---•-----••---•••-----•---•-••--.........._.....••--•-----•--•-••----••••••----•--•---•••--•------------•--•-•-------•-••-••-•-•---------
`.11
Permit No....f... .......1_�_ . .
--------------------- Issued.......................................................
------
Date
� � l
.J
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...... .......OF.... :1 ...:... ----------_:..................................
Appliratinn for Disposal Works Tonstnution 1hrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at: /
ocatio Address --•-••• •-•-•__•-•-or Lot No.
....... (A-t�e ......--.�.k' ---- =- ---------------------------------- ---------------
ner -••••••••.................•.....Address
nstaller Address
Q Type of Building Size Lot/Z,._2/4!_=__.Sq. feet
aDwelling—No. of Bedrooms.... ...................................Expansion Attic ( ) Garbage Grinder ( )
p-, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
al Other fixtures ____________________________ _
W Design Flow.............................. _..____gallons per person per day. Total daily flow-_2. ...........................gallons.
9 Septic Tank—Liquid capacity Ae ...gallons Length.!Z ._... WidthX..L:C...... Diameter....--.._... DepthS_.. :"...
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.__------__�.____-- Diameter----------- Depth below inlet_ .:_ ......... Total leaching areas .......sq. ft.
Z Other Distribution box (✓) Dosing tank ( )
'-' Percolation Test Results Performed ...... DateC1_'.Z_s ...................
Test Pit No. 4f�'%_:z__minutes per inch Depth of Test Pit.__--/.z-_.___--- Depth to ground water......__---__-----------
44 Test Pit No. 2...............minutes per inch Depth of Test Pit----e'.2..___.. Depth to ground water-------..._..........
a ...................
-•---------••---•---------------------------------------••-- ---------•.•--•----•••••••-•••---•--------•---•-•-••-•--•--•••--•.....................................•--------•....••-•----•-•--•--•-•---------••--
• ✓ i /� /- //._"' / .r! qi_- g �i✓ice
Description of Soil _.. _ ��i.....-----------------
x
w
----•••...••------------------------------------•-----••••......-----•---------•---•• --••--••--•---••••-••---••••••----••--••------•-•----••••••••••••••••-•--•••••••••••-•-•••..................----
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T:.TtLE4, 5 of the State Sanitary Code—The undersigned 'further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed.........................
-___-___________-------------------••••-------------•-------•- -----------------------••---
Dat�--•�
Application Approved BY 1 •-•-----•--..... L ........_.... v "Z /.:'�__
Date -
Application Disapproved for the following2asons:----•••--•----•-•••---•----•----••-•••-••••••••••••••••••••-......-•--•-......-•--•-•-•---. ---•--------------
----••-•-••-•-•--•--•--•••••--•••-----••--•-------------•--------•••--••-•.._..-••...._..--•-------•••-•- •-----.........•-••••-•--••-•••-•-••-••--••••-•••----••••••--•-----------•-•-•••--•-••••-_..._
j,, Date
PermitNo..l....V....... .t. ....................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................OF.... ".."`""'.....................................................
Turrtifiratr of Trrntplianrr
THIS I TO C FY That;fie I ual e zge Disposal System constructed ) or Repaired ( }
by----------------�-!�'��� _� l � Pf!
................................................................................................I................................................
atv -><.U - Ser --------------------------------------------
has been installed in accordance with the provisions of TIE l Zof 1 T State Sanitary Ctod� as-c)e .abed 'n the
application for Disposal Works Constriction Permit N .__.0........... , dated_.__.-_..-_.-._..___�__`__D._ _...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT itHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.................. ..... ......................... Inspector---. --••-------•--------- _
CERTIFY IN 'v'JRITING
i' THE COMMONWEALTH OF MASSACHUSETTSISTEM VVAS INSTALLED IN STRICT
BOARD OF HEALTH ACCIORDANCE TO PLAN.
\
OF1 ...'.._..!....✓ 5 ..... ................................ FEE. ..........
�i��n��t � nr �.�n�#rltr�irrn rrnti� -
Permission is hereby granted.. 4 ..� ----------------------------•-•...........----••.............---....--
to Construct) or Repair ( ) an Individual Sewage Dis osal System
_ 7
.�T -d 1 t !_. . .`.... . .........
•....................ram._ v
Street 5 C/ i
as shown on the application for Disposal Works Construction Permit N __ ..._....._ Dated.-.V__......... r_ _ ......
t
_
Brd ofHath
ATE V
�t, r �✓ ... ..................................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
Xo-t 10 Scale I n-20 ' Litt Cape &5r merr iru' 1V
Date 10-5-86 . . 49 hay bog P6ad
Idyc,,u*i,�,., Ma. 02601
G.2 '
9-to4.t nn
Pane
Pot
-6 'x 4 ' pit 429 7
=204 f
g 29.®2 23'
(Ptivate) ° 392
1 ; .
.cot
000
PRoPoSF C2
t. .C'o t
49
007"
_ - ....._.. ._£xp � i..
b R i r-=
27.3
Watt to b
ado ! .. j . ..
.Pot 12
i
nd pti ja f e No Scale
I - C9 gnd.
r 000
0 -till
W/2 ' 4tOne �t
, I f
Sk-Each Nan of .W and in Id ya z tii�., Ma.
9o�t Chaatez lduc�h.eA
13e i,u tot....I l-- as down on a ptan�aecoaded :in, . .-__..
book 164 pace 57:
£d eua tc o" down ace on an a�.asced &tu*.
feat /tit ;'1/)-6 19! J 8o a2cZ o T ea�,th
No wa xA encounteaed
.('&idtAan 2 nr-in. peg 1"
9.p.1 z9.7 29.7
I
ncedi,�ax. iscedium ' ''
nand sand ,
DESIGNING ENGINEER MUST SUPERVISE iP A
atonea j-tone4 INSTA'_LATION AND CERTIFY IN WRITING � S
THE ;SYSTEM WAS INSTALLED IN STRICT r
.;' ANCE TO PLAN. z
pg,00
tdl�•8�4 4`'1
o F --
s
o
17.E 17.5
----------- --------
PROVIDE PRECAST CONCRETE GENERAL NOTES
T.O.F. EL.=-40.6' +- EXTENSION RISER WITH CONCRETE INISH GRADE OVER D-Box= 3-7.-8'+- 4"SCHEDULE 40 PVC MIN. SLOPE 1 % FINISHED GRADE OVER INFILTRATION= 37.0' - 37.5'
COVER TO WITHIN 6"OF F.G. OVER SLOPE @ 2% MIN.
INLET AND OUTLET COVERS. REMOVABLE COVER OVER RISER TO ACCESS PORT WITH 1. UNLESS OTHERWISE NOTED,ALL SYSTEM COMPONENTS AND CONSTRUCTION
FINISH GRADE
WITHIN 6"OF FINISHED GRADE METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL
ACCESS BOX TO WITHIN
@ FND. EL.= 39.7'+- FINISHED GRADE OVER TANK EL. 39.3'+ 5-DIA. OUTLET(S) INSPECTION PORT w/ACCESS BOX CODE AND ANY APPLICABLE LOCAL RULES.
---------- 6-OFF (ONE PER ROW) SEE NOTE#21
----------------------_- 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE
DESIGN ENGINEER.
Z�
EXISTING 4" PROPOSED 4" 9"MIN. 3. 4"SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL
PVC SEWER PIPE 36"MAX. 9"MIN. SYSTEM UNLESS OTHERWISE NOTED.
SEWER PIPE _j 36"MAX. TOP OF SAS B.O. 34.50'
k
6" 3" 3" DROP MAX F 9. PROVIDE WATERTIGHT 4. TO PREVENT BREAKOUT,THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN
2-DROP MIN 3" MIN.SLOPE @ I% JOINTS (TYP.) ELEVATION =34.50' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS A
10" 4" PVC IN FROM 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S.AND THE TOP OF
14-1 *�5.3'± SEPTIC TANK 4"PVC OUT TO 1.33' THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION.
j LEACHING FACILITY (TYP.) 16"TYP
0.90, 00 n10.1"TYP 5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM.
0 0.
0
12"
CONTRACTOR CONTRACTOR SHALL \ 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL.
I
SHALL VERIFY SIZE 48" VERIFY CONDITION OF OUTLET TEE 35.00 34.83' -
34.07' 33.17' (LAID FLAT) 2.875'(34.5-) 5.75' 7. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK
AND CONDITION OF EXISTING TEES 22"ZABEL FILTER 6"CRUSHED STONE 5.0' (TYP.) FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS
EXISTING SEPTIC AND REPLACE As MODEL#Al 801-4x22 OVER MECHANICALLY (TYP.) NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH
TANK NECESSARY COMPACTED BASE 5'MIN. 11.50, AND DESIGN ENGINEER.
3 OUTLET DISTRIBUTION BOX 20.0'(TYP FOR BOTH ROWS) 8. ELEVATIONS BASED ON APPROXIMATE M.S.L. DATUM OF 40.00' ESTABLISHED
TO BE INSTALLED ON A LEVEL STABLE ON A NAIL SET IN AN OAK TREE AS SHOWN ON PLAN.
BASE. FIRST TWO FEET OF OUTLET GROUND WATER ELEV.= < 25.67' 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION
EXISTING 1,000 GALLON CONCRETE SEPTIC TANK PIPES TO BE LAID LEVEL. THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT
CROSS SECTION VIEW BIODIFFUSER (PROFILE) BIODIFFUSER (END VIEW) 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES
*CONTRACTOR TO VERIFY EXISTING ELEVATION PRIOR SEPTIC TANK PROFILE DISTRIBUTION BOX DETAIL 8 ARC 36HC (#3616BD) BIODIFFUSERS TO THE DESIGN ENGINEER.
TO ANY WORK & NOTIFY ENGINEER IF DIFFERENT. NOT TO SCALE NOT TO SCALE NOT TO SCALE 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONIC. STRUCTURES SHALL BE MADE WATERTIGHT.
----------
11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING
NOTE: ENTIRE PROPERTY IS LOCATED WITHIN A WP DISTRICT. iD TEST PIT DATA REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM
APPROPRIATE AUTHORITY.
PERC NO. 12396 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS
LOCATED UNDER PAVEMENT, DRIVES OR TRAVELED WAYS IN WHICH CASE
INSPECTOR- Donna Z. Miorandi, R.S.
THEY SHALL WITHSTAND H-20 LOADING.
EVALUATOR: Michael Pimentel, E.I.T.
13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES.
DATE: October 20, 2008
APPROXIMATE LOCATION OF EXISTING
Benchmark 1 TEST PIT#: 1 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE
DISTRIBUTION BOX TO BE REMOVED Nail in Oak Tree MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY.
li 1 ELEV TOP 37.50' REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY,
Elev. =40.00'
APPROXIMATE LOCATION OF EXISTING Approx. M.S.L. MAP 289 ELEV WATER <25.67' FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3).
LEACHING PIT TO BE PUMPED AND
15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN
F11 I F-r-) kAlITH 171 FAN- r'0AR!7-F SAND PARCEL10 PERC RATE <2 min./inch
SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK.
LO
DEPTH OF PERC 34"-52"
16.
PROPOSED INSPECTION PORT MAP 289 0 PROPOSED PROJECT IS LOCATED WITHIN:
PROPOSED ACCESS PORT
PARCEL160 • TEXTURAL CLASS: 1 ASSESSOR'S MAP 289 PARCEL 12
WITH ACCESS BOX TO •
TREELINE (TYP) OWNER OF RECORD: ERIC VOHNO TKA
GRADE (TYP OF 2)
z ADDRESS: 93 UNION STREET
"
Fill 37.50'
0 WESTPORT, MA 02790
EXISTING 1000 GALLON SEPTIC TANK TO G 4' 37.17'
Loamy Sand
ou A FEMA FLOOD ZONE C
BE UTILIZED AS PART OF THIS DESIGN 1 OYr 3/1
10" 36.67' COMMUNITY PANEL# 250001 0008 D
Loamy Sand
S87051130"W 1 OYr 5/6
129.48'
B 17. DEED REFERENCE: BOOK 19984, PAGE 239
34.67'
CB/DH 18. PLAN REFERENCE: PLAN BOOK 164, PAGE 57
Perc
-5 0" -SEN 33.17' 19. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION.
/ !------ 20. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY
FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT ASSUME ANY LIABILITY
ra
�4 'N •
FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE.
U41 • Medium-Coirse
C 21. A 4"PERFORATED SCH.40 PVC PIPE SHALL BE PLACED IN A VERTICAL POSITION TO A
Sand
35x5
LP DEPTH OF THE BOTTOM OF THE SAS AND EXTEND TO WITHIN 3"OF FINISH GRADE. A
2.5Y 6/6(Loose) REMOVABLE THREADED CAP SHALL BE PLACED ON THE TOP TO ALLOW FOR INSPECTIONS.
(4) HC1 BH
(3)
0
0.13 LOCUS PLAN
0 TP
3 . SCALE: 1"= 1000'
i 142" 25.67'
co I No Mottling, Standing or Weeping Observed
co ------- ----------
TP2 #83
0. 38.0' Cn
245, EXISTING DESIGN DATA
TEST PIT DATA LEGEND
2-BEDROOM
5OX0 EXISTING SPOT GRADE
12396
0 ' DWELLING MAP 289 PERC NO.
0 NUMBER OF BEDROOMS (DESIGN) 2* i
TOF 40.6'± CP. 1 INSPECTOR: Donna Z. Miorandi, R.S. 50 EXISTING CONTOUR
a rn
L
(I PARCEL DESIGN FLOW 110 __jGAUDAY/BEDROOM
(P DECK DECK EVALUATOR: Michael Pimentel, E.I.T. -cm- PROPOSED CONTOUR
CP (2) Cr. TOTAL DESIGN FLOW 220 GAUDAY DATE: October 20, 2008
'0
0
440 GAUDAY D/H/W EXISTING OVER HEAD UTILITIES
n LP 38 DESIGN FLOW X 200 % = TEST PIT#: 2
USE EXISTING 1,000 GALLON SEPTIC TANK
ICY' LU=v rop 38.00'
W-W EXISTING WATER LINE
DEED RESTRICTION TO BE FILED ELEV WATER <26.17'
HC2
0. PERC RATE TEST PIT LOCATION
�-Am /
INSTALL 8 - ARC 36HC (#3616BD) BIODIFFUSERS i DEPTH OF PERC EXISTING LEACHING PIT
0 TEXTURAL CLASS: 1
G, m --- ,� I� '_ - SYSTEM CAPACITY T EXISTING 1,000 GALLON SEPTIC TANK
-A
(TOTAL L.F. OF BIODIFFUSERS)(7.8 SF/LF)(0.74 GPD/SQ.FT.) GPD PROPOSED 4"SOLID SCHEDULE 40 PVC PIPE
vl/
0"
[3
BIT. DRIVEWAY (
MAP 289 40.0')(7.8 SF/LF)(0.74 GAUSQ.FT.)= 230.9 GAL. LEACHING DAY 38.00'
Fill PROPOSED DISTRIBUTION BOX- '
4 37.67
Loamy Sand
co PARCEL12 A I OYr 3/1 PROPOSED ARC 36HC(#3616BD)BIODIFFUSER
i y\ 11,773 S.F. TOTALS: 1 10" 37.17'
i B Loamy Sand
TOTAL NUMBER OF BIODIFFUSERS: 8 1 34" 1 OYr 5/6 35.17'
GUY WIRE TOTAL NUMBER OF COUPLINGS: 0
TOTAL LEACHING AREA: 312.0 SQ.FT. REV DATE BY
ESCRIPTION
TOTAL LEACHING CAPACITY: 230.9 GAL./DAY ------- ------
N88'40'10"E NOTE: PROPOSED SEPTIC SYSTEM UPGRADE
UP Is
136.4V EFFECTIVE LEACHING AREA OF 7.80 SF/LF OBTAINED FROM THE PREPARED FOR:
\--PROPOSED DISTRIBUTION BOX DEPARTMENT OF ENVIRONMENTAL PROTECTION APPROVAL LET C Medium-Coarse CAPEWIDE ENTERPRISES
"MODIFIED CERTIFICATION FOR GENERAL USE" ISSUED TO Sand
PROPOSED TOTAL 8 ARC 36HC BIODIFFUSERS MAP 289 ADVANCED DRAINAGE SYSTEMS, INC. ON OCTOBER 3, 2003(LAST 2.5Y 6/6
(4 BIODIFFUSERS EACH TRENCH) PARCEL13 MODIFIED JULY 23, 2008). TRANSMITTAL NUMBER W000052. (Loose) LOCATED AT
83 FROST LANE
C HYANNIS, MA
SWING TIE MEASUREMENTS 142" 26.17' SCALE: 1 INCH 10 FT. DATE: OCTOBER 21, 2008
DESCRIPTION HC1 HC2 No Mottling, Standing or Weeping Observed 0 5 10 2 1 0 4 1 0 FEET
BIODIFFUSER CORNER(1) 28.9' 35.0' 1
L PREPARED BY:
RESERVED FOR BOARD OF HEALTH USE JC ENGINEERING, INC.
BIODIFFUSER CORNER(2) 39.1* 43.5' CIVIL
2854 CRANBERRY HIGHWAY
NOTE: BIODIFFUSER CORNER(3) 36.6' 57.5' T EAST WAREHAM, MA 02538
1.) MAGNETIC MARKING TAPE SHALL BE PLACED ALONG SITE PLAN- BIODIFFUSER CORNER(4) 25.9' 51.4' 508.273..0377
THE TOP EDGE OF EACH SEPTIC SYSTEM COMPONENT. SCALE: 1"= 10' Drawn By: BSM Designed By:MCP Ch,hecked By:JLC JOB No.1512
_]
----------- -------- ------ ------- -------- -------- --------